ED Coding and Reimbursement Alert

Question: We are trying to code a chest exploration following a gunshot wound. Should we use an unlisted procedure code for this?

Codify Subscriber

Answer: No, although circumstances would vary depending on the specific case and documentation. The code set 20100-20103 is available to describe surgical exploration and enlargement of the wound, extension of dissection (to determine penetration), debridement, removal of foreign body(s), ligation or coagulation of minor subcutaneous and/or muscular blood vessel(s), of the subcutaneous tissue, muscle fascia, and/or muscle, not requiring thoracotomy or laparotomy. If the treatment progressed to a full and formal thoracotomy, code 32110 (Thoracotomy; with control of traumatic hemorrhage and/or repair of lung tear) would be a consideration, as well.

Based on your description, the most appropriate code would likely be 20101 (Exploration of penetrating wound [separate procedure]; chest.)

Bonus: If the ED physician uses single-layer closure to repair a heavily contaminated wound that requires “extensive cleaning or removal of particulate matter,” you may be justified in reporting intermediate repairs (12031-12057), according to CPT^®. This caveat allows you to report intermediate codes for well-documented single-layer repairs that are heavily contaminated, but your documentation must include descriptive details about the procedure such as “prior to closure, the wound required the physician to perform extensive cleaning and removal of particulate matter of the site.”